Terminal care: present services and future priorities.

Since 1975 hospices and other specialist services for terminal cancer have expanded rapidly. In December 1980 this survey found 72 such services in Britain providing 58 inpatient units, 32 home care teams, and eight hospital support teams. Many were outside the NHS. Inpatient units provided 1297 beds (modal size 21-25 beds) and dealt with under 7% of deaths from cancer. Home care teams provided 76.5 full-time equivalent nurses (modal size two nurses). Regional variations were considerable: from 10.9 beds/million population in Trent to 48.5 beds/million in South-west Thames; no home care nurses in Mersey and Wales, and 5.1 nurses/million in Wessex. Of 58 more services being planned, the 17 starting in 1981 will not substantially alter these regional imbalances. Respondents'' opinions suggest a target of 40-50 inpatient unit beds/million population. This might be reduced if hospitals were better equipped to deal with these patients. Suggested priorities are to redress regional inequalities, develop home care and hospital support teams rather than inpatient units, and improve teaching and training. Co-ordination of plans between the NHS and the voluntary sector is needed.     

Cervical cancer screening programme in Finland with an example on implementing alternative screening methods

In Finland (population 5 million) the organised Pap screening programme for preventing cervical cancer has been in action already for 45 years. Women aged 30 to 64 are targeted (N 1.25 million) and the screening interval is five years. The programme invites women seven times in a lifetime; the attendance rate per one screening invitational round is 73%. The programme has affected markedly the cervical cancer rates in our country. During the decennia of its action there has been about 80% decrease in the age-adjusted cervical cancer incidence and mortality rates. The current age-standardised incidence rate is 4 and mortality rate 1 per 100,000 woman-years. In the current article we describe the organisational aspects of the programme; and pay attention to renovation of the programme taken place during the last decade when novel technological alternatives have been started to be used as the screening tests. By expanding the coverage and compliance of screening we still expect to increase the impact of the programme. Same time, efforts are needed to avoid overuse of services due to spontaneous screening, in order to decrease potential adverse effects and improve overall cost-effectiveness. A large-scale public health policy trial on Human papillomavirus (HPV) screening is on-going. Cross-sectional information available thus far suggests promising results. Follow-up of cancer rates after screening episodes are still required to evaluate optimal screening policies (e.g., screening intervals by age groups, and starting and stopping ages). We propose speeding up the use of modern technological alternatives in organised screening programmes.     

Contribution of general practitioner hospitals in Scotland.

The results of a survey of 64 Scottish general practitioner hospitals showed that in 1980 these hospitals contained 3.3% of available staffed beds in Scotland; 13.6% of the resident population had access for initial hospital care, and 14.5% of Scottish general practitioners were on their staffs. During the year of the survey they discharged 1.8% of all non-surgical patients, treated almost 100 000 patients for accidents and emergencies and 140 000 outpatients, and 4.4% of all deliveries in Scotland were carried out in the hospitals surveyed. Most communities which are served by general practitioner hospitals in Scotland are rural and on average are more than 30 miles from their nearest district general hospital. The contribution that these small hospitals make to the overall hospital workload has not previously been estimated. It has been shown nationally to be small but not inconsiderable . In terms of the contribution to the health care of the communities they serve it cannot and should not be underestimated.     

Health problems and health care for adolescents in residential facilities in Quebec.

The health problems of 160 adolescents in four residential facilities of the Quebec social welfare court were studied. At the time of admission 44% had at least one problem requiring consultation with a specialist and 80% had an average of two problems requiring primary care. The medical records of 106 youngsters in two re-education centres were also reviewed and similar results were noted. The health services available, particularly physical examination and laboratory testing at the time of admission and arrangements for referral and follow-up were judged to be insufficient in most centres. Although society has taken custody of these adolescents, no one is responsible for their health care. Since February 1976 the social welfare court residential facilities and the network involved in the care of socially disturbed youngsters have been undergoing reorganization. Health programs and services ought to be part of this reorganization, and private physicians, hospitals and government each should have a role in the establishment and functioning of these programs.     

Mental health services in the Arab world

This paper summarizes the current situation of mental health services in the Arab world. Out of 20 countries for which information is available, six do not have a mental health legislation and two do not have a mental health policy. Three countries (Lebanon, Kuwait and Bahrain) had in 2007 more than 30 psychiatric beds per 100,000 population, while two (Sudan and Somalia) had less than 5 per 100,000. The highest number of psychiatrists is found in Qatar, Bahrain and Kuwait, while seven countries (Iraq, Libya, Morocco, Somalia, Sudan, Syria and Yemen) have less than 0.5 psychiatrists for 100,000 population. The budget allowed for mental health as a percentage from the total health budget, in the few countries where information is available, is far below the range to promote mental health services. Some improvement has occurred in the last decade, but the mental health human resources and the attention devoted to mental health issues are still insufficient.     

The role of hospital-based cancer registries in low and middle income countries-The Nigerian Case Study

Background: The incidence of cancer continues to rise all over the world and current projections show that there will be 1.27 million new cases and almost 1 million deaths by 2030. In view of the rising incidence of cancer in sub-Saharan Africa, urgent steps are needed to guide appropriate policy, health sector investment and resource allocation. We posit that hospital based cancer registries (HBCR) are fundamental sources of information on the frequent cancer sites in limited resource regions where population level data is often unavailable. In regions where population based cancer registries are not in existence, HBCR are beneficial for policy and planning. Materials and methods: Nineteen of twenty-one cancer registries in Nigeria met the definition of HBCR, and from these registries, we requested data on cancer cases recorded from January 2009 to December 2010. 16 of the 19 registries (84%) responded. Data on year hospital was established; year cancer registry was established, no. of pathologists and types of oncology services available in each tertiary health facility were shown. Analysis of relative frequency of cancers in each HBCR, the basis of diagnosis recorded in the HBCR and the total number of cases recorded by gender was carried out. Results: The total number of cancers registered in these 11 hospital based cancer registries in 2009 and 2010 was 6484. The number of new cancer cases recorded annually in these hospital based cancer registries on average was 117 cases in males and I77 cases in females. Breast and cervical cancer were the most common cancers seen in women while prostate cancer was the commonest among men seen in these tertiary hospitals. Conclusion: Information provided by HBCR is beneficial and can be utilized for the improvement of cancer care delivery systems in low and middle income countries where there are no population based cancer registries.     

Status of Emergency Obstetric Care in Six Developing Countries Five Years before the MDG Targets for Maternal and Newborn Health

Background

Ensuring women have access to good quality Emergency Obstetric Care (EOC) is a key strategy to reducing maternal and newborn deaths. Minimum coverage rates are expected to be 1 Comprehensive (CEOC) and 4 Basic EOC (BEOC) facilities per 500,000 population.

Methods and Findings

A cross-sectional survey of 378 health facilities was conducted in Kenya, Malawi, Sierra Leone, Nigeria, Bangladesh and India between 2009 and 2011. This included 160 facilities designated to provide CEOC and 218 designated to provide BEOC. Fewer than 1 in 4 facilities aiming to provide CEOC were able to offer the nine required signal functions of CEOC (23.1%) and only 2.3% of health facilities expected to provide BEOC provided all seven signal functions. The two signal functions least likely to be provided included assisted delivery (17.5%) and manual vacuum aspiration (42.3%). Population indicators were assessed for 31 districts (total population = 15.7 million). The total number of available facilities (283) designated to provide EOC for this population exceeded the number required (158) a ratio of 1.8. However, none of the districts assessed met minimum UN coverage rates for EOC. The population based Caesarean Section rate was estimated to be <2%, the maternal Case Fatality Rate (CFR) for obstetric complications ranged from 2.0–9.3% and still birth (SB) rates ranged from 1.9–6.8%.

Conclusions

Availability of EOC is well below minimum UN target coverage levels. Health facilities in the surveyed countries do not currently have the capacity to adequately respond to and manage women with obstetric complications. To achieve MDG 5 by 2015, there is a need to ensure that the full range of signal functions are available in health facilities designated to provide CEOC or BEOC and improve the quality of services provided so that CFR and SB rates decline.     

Impact of the NHS reforms on English hospital productivity: an analysis of the first three years.

OBJECTIVES: To evaluate the effect of purchaser mix, market competition, and trust status on hospital productivity within the NHS internal market. METHODS: Hospital cost and activity data were taken from routinely collected data for acute NHS hospitals in England for 1991-2 to 1993-4. Cross sectional and longitudinal regression methods were used to estimate the effect of trust status, competition, and purchaser mix on average hospital costs per inpatient, after adjusting for outpatient activity levels, casemix, teaching activity, regional salary variation, hospital size, scale of activity, and scope of cases treated. RESULTS: Real productivity gains were apparent across the study period for NHS hospitals on average. Casemix adjustment drastically improved cross sectional comparisons between hospitals. Gaining trust status and increasing host district purchaser share were associated with productivity increases after adjustment for casemix, regional salary differences, and hospital size and scope. Hospitals that became trusts during the study period were on average less productive at the beginning of the period than those that did not, and there were no significant productivity differences between trust waves at the end of the period in 1993-4. Market concentration was not associated with productivity differences. CONCLUSION: Further analysis is needed to determine whether overall and trust associated productivity gains are transient effects, one off shifts, or self perpetuating reorientations of organisational behaviour. Hospitals may have chosen to become trusts because they anticipated being able to increase productivity. Increases in the proportions of small purchasers were associated with increasing costs. Importantly, this study could not adjust for changes in the quality of care.     

Cutaneous malignant melanoma in Scotland: incidence,survival, and mortality, 1979-94. The Scottish Melanoma Group.

OBJECTIVE: To determine the changing incidence of and mortality from cutaneous malignant melanoma in Scotland from 1979 to 1994. DESIGN: Detailed registration of clinical and pathological features, surgical and other treatment, and follow up of all cases of cutaneous malignant melanoma diagnosed from 1979 to 1994 and registered with specialist database for Scotland. SETTING: Scotland. SUBJECTS: 6288 patients with invasive primary cutaneous malignant melanoma diagnosed between 1 January 1979 and 31 December 1994. RESULTS: The annual age standardised incidence of cutaneous malignant melanoma rose significantly from 3.5 to 7.8 per 100,000 per year in men and from 6.8 to 12.3 per 100,000 per year in women (P < 0.001 for both). World standardised rates increased from 2.7 to 6.0 per 100,000 per year in men and 4.6 to 8.50 per 100,000 in women. The incidence of melanoma continued to increase significantly in men of all ages during the study, but the rate stabilised in women after 1986. Mortality from cutaneous malignant melanoma was 1.3 per million per annum in men in 1979, rising to 2.3 per million per annum in 1994 (P < 0.01); it was 2.4 per million per annum in women in 1979, falling to 1.9 per million per annum in 1994 (P = 0.09). The underlying mortality trends showed a continuing rise for men but a downward trend for women that was not significant (P = 0.09). In men, melanoma free survival was 69% at 5 years and 61% at 10 years; in women the corresponding rates were 82% and 75%. Younger patients had higher survival rates, which were not entirely explained by thinner tumours. Over the 15 year period, survival rates improved by 12% overall, only partly owing to thinner tumours. CONCLUSIONS: In Scotland the incidence of melanoma in women has stabilised, while mortality associated with melanoma in women shows a downward trend.     

Incidence of severe acute renal failure in adults: results of a community based study.

OBJECTIVE--To determine the age related incidence of severe acute renal failure in adults in two health districts in England. DESIGN--Prospective study of patients identified as having severe acute renal failure within a two year period; subsequent monitoring of outcome for a further two years. SETTING--Two health districts in Devon. SUBJECTS--Those adults in a population of 444,971 who developed severe acute renal failure (serum creatinine concentration > 500 mumol/l) for the first time during two years, with subsequent fall of the serum creatinine concentration below the index value. MAIN OUTCOME MEASURES AND RESULTS--125 adults (140 per million total population yearly, 172 per million adults) developed severe acute renal failure, of whom 90 (72%) were over 70. Age related incidence rose from 17 per million yearly in adults under 50 to 949 per million yearly in the 80-89 age groups. In 31 patients (25%) the cause was prostatic disease, which was related to a good prognosis (84% (26) alive at three months). Overall survival was 54% (67) at three months and 34% (42) at two years and was not significantly age related. 18 per million total population yearly (22 per million adult population) received acute dialysis. Referral rate for specialised opinion was 51 per million total population yearly with an estimated appropriate referral rate of 70 per million per year. CONCLUSIONS--The incidence of severe acute renal failure in the community is at least twice as high as the incidence reported from renal unit based studies. Prostatic disease, a preventable and treatable problem, is the most common cause. Survival figures indicate that age alone should not be a bar to specialist referral or treatment.     

Psychiatric services in general hospitals: a report of the Northern California Psychiatric Society's committee on the need for psychiatric services in general hospitals

A study made by a special committee appointed for the purpose by the Northern California Psychiatric Society found that a real need exists for local psychiatric services in general hospitals of the Northern California area. Such services can be provided readily-and in some communities are already available. A broad segment of the population looks to the general hospital to provide diagnosis and care and so enable the patient's prompt recovery from psychiatric disorders. The study further emphasizes the importance of such factors as a competent psychiatric chief, adequate staff and personnel and good planning in organizing inpatient and outpatient facilities and integrating treatment so that all the functions of the hospital are available to psychiatric patients. Granted these special considerations, the services can be provided more easily than many physicians, including some psychiatrists and administrators, suppose.     

Liberty and psychiatry

The security facilities available in one regional health authority area have been surveyed. The simultaneous run-down of the large mental hospitals and the open-door policy have resulted in a lack of facilities for mentally abnormal offenders, and the increasing scarcity of common lodging houses has exacerbated the problem. Newer psychiatric units associated with general hospitals have been mainly concerned with patients suffering from neurosis or acute psychoses. The failure to develop other services to deal with offenders has seriously overburdened both the penal system and the special hospitals.     

Voluntary Health Insurance Coverage in California, 1952 to 1963—Report of the Bureau of Research and Planning

More than seven out of every ten of an estimated civilian population of 17.3 million people in California were covered under some form of voluntary health insurance at the close of 1963.Between 1952 and 1963, the number of Californians covered for hospital expenses increased from 5.7 million to 12.3 million; for surgical expenses from 5.4 million to 11.6 million; and for regular medical expenses from 3.0 million to 10.1 million.The percentage covered by health insurance also rose significantly: for hospitalization, from 51.3 to 71.0 per cent; for surgical, from 48.2 to 67.1 per cent; and for regular medical from 27.2 to 57.9 per cent. The rate of increase in hospitalization coverage was slightly higher in California than in the total U.S.; however, the per cent of persons covered remains lower. For surgical coverage, both the rate of increase and the per cent covered are lower in California. For regular medical, growth rates in California and in the U.S. were similar, however the over-all per cent covered is significantly higher in California.Major medical coverage, which has shown the fastest growth rate, covered only 0.4 per cent of the U.S. population in 1952 and 17.1 per cent by the end of 1963. Comparable figures for California are not available.     

Reorganising specialist cancer surgery for the twenty-first century: a mixed methods evaluation (RESPECT-21)

Background

There are longstanding recommendations to centralise specialist healthcare services, citing the potential to reduce variations in care and improve patient outcomes. Current activity to centralise specialist cancer surgical services in two areas of England provides an opportunity to study the planning, implementation and outcomes of such changes. London Cancer and Manchester Cancer are centralising specialist surgical pathways for prostate, bladder, renal, and oesophago-gastric cancers, so that these services are provided in fewer hospitals. The centralisations in London were implemented between November 2015 and April 2016, while implementation in Manchester is anticipated in 2017.

Methods/Design

This mixed methods evaluation will analyse stakeholder preferences for centralisations; it will use qualitative methods to analyse planning, implementation and sustainability of the centralisations (‘how and why?’); and it will use a controlled before and after design to study the impact of centralisation on clinical processes, clinical outcomes, cost-effectiveness and patient experience (‘what works and at what cost?’). The study will use a framework developed in previous research on major system change in acute stroke services. A discrete choice experiment will examine patient, public and professional preferences for centralisations of this kind. Qualitative methods will include documentary analysis, stakeholder interviews and non-participant observations of meetings. Quantitative methods will include analysis of local and national data on clinical processes, outcomes, costs and National Cancer Patient Experience Survey data. Finally, we will hold a workshop for those involved in centralisations of specialist services in other settings to discuss how these lessons might apply more widely.

Discussion

This multi-site study will address gaps in the evidence on stakeholder preferences for centralisations of specialist cancer surgery and the processes, impact and cost-effectiveness of changes of this kind. With increasing drives to centralise specialist services, lessons from this study will be of value to those who commission, organise and manage cancer services, as well as services for other conditions and in other settings. The study will face challenges in terms of recruitment, the retrospective analysis of some of the changes, the distinction between primary and secondary outcome measures, and obtaining information on the resources spent on the reconfiguration.

     

Voluntary Health Insurance Coverage in California, 1961: A Report of the Bureau of Research and Planning, California Medical Association

Almost 7 out of every 10 of the estimated population of 16.2 million persons in California, were covered under some form of voluntary health insurance at the end of 1961. The forms of protection included hospital, surgical, regular medical and major medical expense benefits. The per cent of the civilian population of California covered for surgical benefits was slightly over 66 per cent, while 56 per cent were covered for regular medical expense benefits. Comparable percentages for the United States are approximately 74 per cent (hospital), 69 per cent (surgical), and 51 per cent (regular medical). While the percentage of the State's population covered for hospital and surgical expenses is below that for the United States, it is higher for regular medical expense benefits. The rate of increase in coverage for the different forms of health care protection in California exceeded the rate of population growth during the one-year period ending 1961. The foregoing summary and the information in the accompanying text, does not reflect the total number of persons in California who receive or are eligible for health care services. A large variety of government financed programs on local, state and federal levels either finance or provide such services to an estimated 40 to 50 per cent of the California population, which does not have voluntary health insurance coverage. No current data are available regarding the number of persons who do not desire voluntary health insurance coverage for a variety of personal or financial reasons.     

PSYCHIATRIC SERVICES IN GENERAL HOSPITALS—A Report of the Northern California Psychiatric Society's Committee on the Need for Psychiatric Services in General Hospitals

A study made by a special committee appointed for the purpose by the Northern California Psychiatric Society found that a real need exists for local psychiatric services in general hospitals of the Northern California area. Such services can be provided readily—and in some communities are already available. A broad segment of the population looks to the general hospital to provide diagnosis and care and so enable the patient''s prompt recovery from psychiatric disorders. The study further emphasizes the importance of such factors as a competent psychiatric chief, adequate staff and personnel and good planning in organizing inpatient and outpatient facilities and integrating treatment so that all the functions of the hospital are available to psychiatric patients. Granted these special considerations, the services can be provided more easily than many physicians, including some psychiatrists and administrators, suppose.     

Current Estimates of the Economic Cost of Obesity in the United States

This study was undertaken to update and revise the estimate of the economic impact of obesity in the United States. A prevalence-based approach to the cost of illness was used to estimate the economic costs in 1995 dollars attributable toobesity for type 2 diabetes mellitus, coronary heart disease (CHD), hypertension, gallbladder disease, breast, endometrial and colon cancer, and osteoarthritis. Additionally and independently, excess physician visits, work-lost days, restricted activity, and bed-days attributable to obesity were analyzed cross-sectionally using the 1988 and 1994 National Health Interview Survey (NHIS). Direct (personal health care, hospital care, physician services, allied health services, and medications) and indirect costs (lost output as a result of a reduction or cessation of productivity due to morbidity or mortality) are from published reports and inflated to 1995 dollars using the medical component of the consumer price index (CPI) for direct cost and the all-items CPI for indirect cost. Population-attributable risk percents (PAR%) are estimated from large prospective studies. Excess work-lost days, restricted activity, bed-days, and physician visits are estimated from 88,262 U. S. citizens who participated in the 1988 NHIS and 80,261 who participated in the 1994 NHIS. Sample weights have been incorporated into the NHIS analyses, making these data generalizable to the U. S. population. The total cost attributable to obesity amounted to $99. 2 billion dollars in 1995. Approximately $51. 64 billion of those dollars were direct medical costs. Using the 1994 NHIS data, cost of lost productivity attributed to obesity (BMI≥30) was $3. 9 billion and reflected 39. 2 million days of lost work. In addition, 239 million restricted-activity days, 89. 5 million bed-days, and 62. 6 million physician visits were attributable to obesity in 1994. Compared with 1988 NHIS data, in 1994 the number of restricted-activity days (36%), bed-days (28%), and work-lost days (50%) increased substantially. The number of physician visits attributed to obesity increased 88% from 1988 to 1994. The economic and personal health costs of overweight and obesity are enormous and compromise the health of the United States. The direct costs associated with obesity represent 5. 7% of our National Health Expenditure in the United States .     

Profiles

The Canadian Medical Association (CMA) recognizes that there is justification for abortion on medical and nonmedical socioeconomic grounds and that such an elective surgical procedure should be decided upon by the patient and the physician(s) concerned. Ideally, the service should be available to all women on an equitable basis across Canada. CMA has recommended the removal of all references to hospital therapeutic abortion committees as outlined in the Criminal Code of Canada. The Criminal Code would then apply only to the performance of abortion by persons other than qualified physicians or in facilities other than approved or accredited hospitals. The Canadian Medical Association is opposed to abortion on demand or its use as a birth control method, emphasizing the importance of counselling services, family planning facilities and services, and access to contraceptive information.     

How many physicians does Canada need to care for our aging population?

BACKGROUND: There is concern that the aging of Canada''s population will strain our health care system. The authors address this concern by examining changes in the physician supply between 1986 and 1994 and by assessing the availability of physicians in 1994 relative to population growth and aging, and relative to supply levels in the benchmark province of Alberta. METHODS: Physician numbers were obtained from the Canadian Institute for Health Information. The amount of services provided by each specialty to each patient age group was analysed using Manitoba physician claims data. Population growth statistics were obtained from Statistics Canada. Age- and specialty-specific utilization data and age-specific population growth patterns were used to estimate the number and type of physicians that would have been required in each province to keep up with population growth between 1986 and 1994, in comparison with actual changes in the physician numbers. Physician supply in Alberta was used as a benchmark against which other provinces were measured. RESULTS: Overall, Canada''s physician supply between 1986 and 1994 kept pace with population growth and aging. Some specialties grew much faster than population changes warranted, whereas others grew more slowly. By province, the supply of general practitioners (GPs) grew much faster than the population served in New Brunswick (16.6%), Alberta (6.5%) and Quebec (5.3%); the GP supply lagged behind in Prince Edward Island (-5.4%). Specialist supply outpaced population growth substantially in Nova Scotia (10.4%), Newfoundland (8.5%), New Brunswick (7.3%) and Saskatchewan (6.8%); it lagged behind in British Columbia (-9.2%). Using Alberta as the benchmark resulted in a different assessment: Newfoundland (15.5%) and BC (11.7%) had large surpluses of GPs by 1994, whereas PEI (-21.1%), New Brunswick (-14.8%) and Manitoba (-11.1%) had substantial deficits; Quebec (37.3%), Ontario (24.0%), Nova Scotia (11.6%), Manitoba (8.2%) and BC (7.6%) had large surpluses of specialists by 1994, whereas PEI (-28.6%), New Brunswick (-25.9%) and Newfoundland (-23.8%) had large deficits. INTERPRETATION: The aging of Canada''s population poses no threat of shortage to the Canadian physician supply in general, nor to most specialist groups. The marked deviations in provincial physician supply from that of the benchmark province challenge us to understand the costs and benefits of variations in physician resources across Canada and to achieve a more equitable needs-based availability of physicians within provinces and across the country.